Table 4. Potential strategies to facilitate system change to improve ear health in Aboriginal and Torres Strait Islander children.

Level	Potential strategies
Paradigm	Examine the physical, social, and economic environment and its interactions with diverse stakeholders to collaboratively develop system level goals Repeatedly and consistently challenge assumptions, values and priorities of the different and diverse actors who can contribute to improving ear health to promote change Develop governance, co-financing, and co-monitoring mechanism to facilitate of multi-sectoral activities to address the social determinants of ear health Develop specific guidance on the governance of working multi-sectorally Identify and work with key decision makers and change agents in the different levels of the system (e.g. State, local government, councils and communities)
Goals	Develop whole system goals that all stakeholders can agree to (e.g. State, local government, councils and communities) and across sectors such as health, education and training, early childcare, environment, and Housing and Public Works, Aboriginal and Torres Strait Islander partnerships
System structure	Enhance connections across the system
	Establish and articulate simple rules collaboratively and cross-sectorally
	Include interventions that focus on changing the physical, social, and economic environment to complement individualized approaches
Knowledge, feedback and delays	Build ongoing feedback and monitoring into the system with flexibility to adjust intervention’s based on feedback Minimise delays in feedback and information flows at different level of the system Monitor changes in social and political context and community norms and respond where activities are not having the desired effect (e.g. changes in government and policy, changes in practices in relation to ear health as well as practices such as changes in services and service utilisation) Include process and summative evaluation to understand what works, how and in what contexts and monitor changes in patterns that are indicative of change as outcomes may not be observed in short timeframes (e.g. changes in presentations at primary health care facilities or changes in school attendance Alignment with the Recommendations for Clinical Care Guidelines on the Management of OM in Aboriginal and Torres Strait Islander Populations for surveillance and diagnosis Provide timely, clear and truthful feedback to stakeholders at all levels of the system in ways appropriate for the target population Engage a diverse range of stakeholders at different levels of the system in feedback processes with an emphasis on both qualitative and quantitative feedback (e.g. change in number of clinicians using OM clinical guidelines, changes in levels of behavioural risk factors associated with OM, changes in knowledge and/or skills to prevent and manage OM in service providers and affected population)
Structural elements	Pay attention to context, identifying potential bottlenecks and contextual factors that enable or hinder the required change (e.g. lack of equipment capacity to use it, bottlenecks in delivery of sound field systems, contextual factors that prevent implementation of OM clinical guidelines, or limit teaching practices that support learning for children with poor ear health) Iterative negotiations with stakeholders to understand context and facilitate change processes at the different levels of the system